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Quest

PEDIATRIC

DENTAL GROUP S.TROY M I L L E R , D O S

210 Beaullieu Dr. · Lafayette, LA 70508 Tel 337.984.4747 · www.questpediatricdentalgroup.com GENERAL INFORMATION AND CONSENT We are pleased to receive your child as a patient in our office and feel honored by the confidence you have placed with us. We sincerely desire to make his or her visits as pleasant as possible. We feel that we can better establish patient-doctor relationships if our parents and patients are familiar with the service and procedures of this office. INITIAL VISIT: Each child receives a thorough examination on their first appointment. It usually includes a prophylaxis (cleaning of the teeth), topical fluoride, and dental x-rays, if they are needed. Oral hygiene instructions will be given to the patient and reviewed with the parent along with dietary recommendations. We employ all procedures available to reduce radiation risk including thyroid and gonadal lead apron, collimated x-ray machine, and the fastest film available today. We eel that is is extremely important for a child to have a full mouth x-ray (panorex) starting around the age of 5 or 6 to check for any problems such as extra permanent teeth, congenially missing teeth, cysts, or eruption problems. PARENTS MAY ACCOMPANY THEIR CHILD: We have an open door policy in our practice. We want our parents to participate in their child's dental education and feel that it is important that they support our recommendation. We feel that we can prevent most of your child's dental problems with a team effort. NITROUS OXIDE (LAUGHING GAS): Frequently, we will employ the "Happy Air Mask" (nitrous oxide) to help reduce anxiety and fear of dental procedures. It is tremendously effective when treating children and is very safe. PREMEDICATION: It is sometimes necessary to premedicate young children with sedatives in order to successfully perform certain dental procedures. If we recommend premedication, the medications and anticipated side effects will be carefully explained before the procedure. Children who have been premedicated will have their vital signs monitored throughout the procedure. HOSPITALIZATION: Some young or handicapped children requiring extensive treatment would benefit by having their work done under general anesthesia in the hospital setting. If we feel that this is a necessary way to treat your child, we will thoroughly discuss hospitalization with you. PREVENTIVE DENTISTRY: Since some areas of Southeast Louisiana are not adequately fluoridated, preventive dentistry is extremely important. The American Academy of Pediatric Dentistry recommends that children who live in a non-fluoridated areas routinely take fluoride supplements (Poly-vi-flor, Luride, Phos-fur, etc) until the age of ten. Fluoride helps strengthen the teeth as they develop. Also, home fluoride rinse is recommended to strengthen the teeth that are presently in the mouth. We highly recommend sealants for the permanent molars and some second primary molars after eruption. ORTHODONTICS: At each six month hygiene appointment your child will be checked for proper eruption of teeth and/or any malocclusion that may be developing. We will inform you of any treatment that we feel is necessary for your child. CHILDREN'S TIME: Although we schedule appointment times for the treatment of your child, our office operates on "children's time". This means that occasionally some of our patients who are not particularly interested in getting their dental work done may take extra time to be made more comfortable and less apprehensive. This will invariably play havoc with our schedule and cause some delays. So let me personally apologize for running behind now! We are guilty of letting our patients manipulate the schedule somewhat when we are trying to give them the best possible dental experience. We also see many emergencies since children may have accidents at home, school or play. APPOINTMENT POLICY: As a growing pediatric dental practice, our schedule is sometimes booked several months in advance. While we understand that some appointments can't be kept, we would like the courtesy of a phone call notifying us so that we may give that appointment to another child.

PLEASE LET US KNOW IF YOU OBJECT TO THE USE OF FLUORIDE, AND/OR X-RAYS. We intend to render dental services to your child as we would our own. If at any time you have questions concerning your child's dental health, please feel free to ask us.

I HAVE READ AND UNDERSTAND THE CONTENTS OF THIS FORM

Parent's Signature_

Child's Name

Reviewed by

Date ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *You May Refuse to sign This Acknowledgment

., have received a copy of this office's Notice of Privacy Practices on behalf of my child/children.

Parent Name

Signature

Date

Child/Children's Name(s) For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: i_J Individual refused to sign Q Communications barriers prohibited obtaining the acknowledgement Q An emergency situation prevented us from obtaining acknowledgement _) Other (Please Specify)

CONSENT & ACKNOWLEDGEMENT

A B C

Patient Information

Date Patient's Name.

Last First City

S. Troy Miller, DDS

Sex

Middle State

Nickname

Address

Street

Zip

Home Phone If patient is a minor, give parent's or guardian's name. Other children in your family that we have seen Whom may we thank for referring you to our office?

Birthdate

Social Security #

Responsible Party Information

Name

Last First Street City City Middle State State Marital Status

Zip

Residence Mailing Address

Street Zip

E-mail address_ Previous Address (if less than 3 yrs.)

Home Ph.

Work Ph.

Cell Ph.

Street

City

State

Zip

Social Security # Employer Spouse's Name

Last

Birthdate _Occupation

Relationship to Patient No. Years Employed Relationship to Patient

First

Middle

Employer Social Security #.

Occupation Birthdate

_ No. Years Employed Work Phone

Dental Insurance Information

Insured's Name Insurance Company Insurance Co. Address Do you have dual coverage? a Yes Q No Insured's Name Insurance Company Insurance Co. Address Insured's Employer Group No. If Yes: Insured's Soc. Sec. # Local No. Group No. Insured's Soc. Sec. # Local No.

Emergency Information

Name of nearest relative not living with you Complete Address I understand that where appropriate, credit bureau reports may be obtained. Signature (Parent's signature if patient is a minor) Updates (date & initial) Phone

Please check any information that is pertinent to your child. Child's interests and hobbies: Medical History

Yes

Is your child in good health? Does your child have regular medical exams? Is your child up to date with immunizations? Is your child taking any medications? If so, please list Has your child been hospitalized since birth? Has your child had any unfavorable reactions to any medicines, if so, please list Child's Physician

No

Emotional disorder Sickle Cell Anemia Bleeding disorder Hearing Disorder Nervous Disorder Heart Condition Mental Condition Speech Disorder Vision Disorder Rheumatic Fever Cerebral Palsy Kidney Disorder Liver Disorder Brain Disorder Tuberculosis Retardation Allergies Hepatitis Diabetes Epilepsy Asthma Autism HIV+ Recurrent Headaches Transfusions Leukemia Cancer Spina Bifida Latex Allergy Pregnant Other

Dental History

Is this your child's first dental visit? If not, date of last visit Has your child had an unfavorable experience at another dental office? Is your child presently on a fluoride supplement? Is your child a finger sucker? Does your child use a pacifier? Has your child ever experienced trauma to the face or jaws? Age the bottle was discontinued What is your water source? Private Well _ Public System Parish where water source is located?

Yes

No

Reason for Today's Appointment

Check up and Cleaning Other Exam Only Evaluate Crowding Toothache 2nd Opinion

PERMISSION:

Since is a minor, it becomes necessary that signed permission be obtained from the parent or guardian before any and/or all dental services can be performed by Dr. Troy Miller. Authorization is hereby granted to Dr. Miller and shall remain in force and in effect until canceled by either party.

Signed

Relationship

Date

MEDICAL HISTORY

RD-009

Information

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